Well Driller License

APPLICATION TO RENEW A WELL DRILLER LICENSE

I. FILING FEE: A nonrefundable fee of $50 is required to accompany the application (Submit form in DUPLICATE)

II. GENERAL: Name of Licensed Well Driller: DBA or Company Name: ______Well Driller License Number: Expiration Date: Mailing Address: City: State: Zip Code: Phone Number: Email: Drivers License #: State of Issue: ______

Applicant is applying to renew a license for the following type(s) of drilling methodologies (check all that apply): Cable tool drilling Air rotary drilling Mud rotary drilling Reverse circulation drilling Jetting and driving wells

III. DRILL RIG SUPERVISORS: List the drill rig supervisors that you employ in the table below (if new to your license, you must attach a completed Drill Rig Supervisor Registration Form). You are responsible for the actions of each drill rig supervisor that is supervising well drilling activities under your direction.

Name of Years Employed by Years of CEU’s completed Drill Rig Supervisor You as a Experience during license/ Drill Rig Supervisor registration period

IV. LIST OF DRILL RIGS: List your active drill rigs in the table below. If a Drill Rig Form has not been filed for any of your active drill rigs, attach a completed Drill Rig Form to this application.

Name of Rig (or ID Number) Number of Years Is a Well Rig Form on File at the Office of in Service the State Engineer?

Application to Renew a Well Driller License Version: December 1, 2014 Page 1 of 3 V. CONTINUING EDUCATION: Please attach copies of form WD-05, Documentation of Continuing Education Hours; complete one form for the licensee and one for each drill rig supervisor employed by the licensee. Form WD-05 shall be accompanied by all applicable Certificates of Course Completion and any other documentation necessary to demonstrate that you and your drill rig supervisors have earned the required continuing education credit hours.

VI. ATTACHMENTS: Is proof of general liability insurance in the amount of $300,000 (or greater) attached? Is proof of bond in the penal sum of $5000 (or greater) attached or is your bond continuous? Is proof of workmen’s compensation insurance attached?

VII. AFFIDAVIT:

I, , being first duly sworn, upon my oath, depose and say that I have carefully read the foregoing applications, statement and attachments, which are a part hereof; that I am familiar with the rules and regulations of the State Engineer pertaining to the drilling of wells and will comply with them, and that each and all of the statements in the application, statement and attachments are true to the best of my knowledge and belief.

Signature of Applicant

State of New Mexico County of

This instrument was acknowledged before me this day of , 20

My Commission Expires Signature of Notarial Officer

VIII. ENDORSEMENT OF CORPORATE SURETY:

I, , Attorney-in-Fact for , of , State of , as surety of the Well Driller’s Bond executed , wherein is the principal, and identified as our Bond No. on file with the State Engineer, Santa Fe, New Mexico, being first duly sworn, upon my oath, depose and say that said bond is now in force and effect and that said bond will remain in force and effect until such time as it may be cancelled in compliance with the rules and regulations of the State Engineer of New Mexico.

Signature of Attorney-in -Fact

State of New Mexico County of

This instrument was acknowledged before me this day of , 20

My Commission Expires Signature of Notarial Officer IX. ENDORSEMENT OF THE STATE ENGINEER:

License No. Expiration Date: Licensed Drilling Methods: This application for renewal is approved and license is hereby reissued to the applicant to drill water wells of the types described above provided that the applicant complies with all rules and regulations of the State Engineer pertaining to wells.

Witness my hand and official seal this day of ,

Tom Blaine P.E., State Engineer

Application to Renew a Well Driller License Version: December 1, 2014 Page 3 of 3